Original Article

A comparison of Cornell and Sokolow-Lyon electrocardiographic

criteria for left ventricular hypertrophy in a military male population
in Taiwan: the Cardiorespiratory fitness and HospItalization Events
in armed Forces study
Fang-Ying Su1, Yi-Hwei Li1, Yen-Po Lin2, Chung-Jen Lee3, Chih-Hung Wang4, Fan-Chun Meng4, Yun-
Shun Yu5, Felicia Lin5, Hsien-Tsai Wu6, Gen-Min Lin4,5,6
1
Department of Public Health, Tzu Chi University, Hualien, Taiwan; 2Department of Emergency Medicine, Tzu Chi General Hospital, Taipei
branch, New Taipei City, Taiwan; 3Department of Nursing, Tzu Chi College of Technology, Hualien, Taiwan; 4Department of Medicine, Tri-Service
General Hospital, National Defense Medical Center, Taipei, Taiwan; 5Department of Electrical Engineering, National Dong Hwa University,
Hualien, Taiwan; 6Department of Medicine, Hualien-Armed Forces General Hospital, Hualien, Taiwan
Contributions: (I) Conception and design: GM Lin, CH Wang; (II) Administrative support: GM Lin; (III) Provision of study materials or patients:
GM Lin; (IV) Collection and assembly of data: GM Lin, CH Wang; (V) Data analysis and interpretation: GM Lin, CH Wang, FY Su, YH Li; (VI)
Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Gen-Min Lin, MD, MPH. Department of Medicine, Hualien-Armed Forces General Hospital, No. 630, Jiali Rd., Xincheng
Township, Hualien 97144, Taiwan. Email: farmer507@yahoo.com.tw.

Background: The Cornell and Sokolow-Lyon electrocardiography (ECG) criteria have been widely used
for diagnosing left ventricular hypertrophy (LVH) in patients with hypertension. However, the correlations
of these ECG criteria with LVH were rarely compared in military members who received rigorous training,
particularly of the Asian male population.
Methods: We compared the Cornell voltage and product criteria with the Sokolow-Lyon criteria for the
echocardiographic LVH in 539 military male members, ages 18–50 years and free of hypertension in the
Cardiorespiratory fitness and HospItalization Events in armed Forces (CHIEF) study in Taiwan. Pearson’s
correlation coefficient was used to determine the association of each ECG criterion with the index of left
ventricular mass (LVM, g)/height (m)2.7. The sensitivities and specificities were estimated using a receiver-
operating characteristics (ROC) curve in relation to the echocardiographic LVH which was defined as LVM
index ≥49 g/m2.7.
Results: The correlations of the Cornell voltage and product criteria (r=0.24 and 0.26 respectively, both
P<0.0001) were stronger than that of the Sokolow-Lyon criteria (r=0.049 and 0.095, and P=0.26 and 0.03
respectively) with the LVM index. Similarly the performances of the Cornell voltage and product criteria for
the echocardiographic LVH [area under curve (AUC): 0.66 and 0.68, both P<0.0001] were superior to that of
the Sokolow-Lyon criteria (AUC: 0.54 and 0.53, both P>0.1) in the area under the ROC curve analysis.
Conclusions: The Cornell ECG criteria for the echocardiographic LVH had better performance than the
Sokolow-Lyon criteria in a young military male cohort in Taiwan.

Keywords: Cornell criteria; echocardiography; electrocardiography (ECG); left ventricular hypertrophy (LVH);
Sokolow-Lyon criteria

Submitted Oct 15, 2016. Accepted for publication Nov 15, 2016.
doi: 10.21037/cdt.2017.01.16
View this article at: http://dx.doi.org/10.21037/cdt.2017.01.16

© Cardiovascular Diagnosis and Therapy. All rights reserved. cdt.amegroups.com Cardiovasc Diagn Ther 2017;7(3):244-251
Cardiovascular Diagnosis and Therapy, Vol 7, No 3 June 2017
Introduction
Left ventricular hypertrophy (LVH) measured by
echocardiography or magnetic resonance imaging studies
has been well regarded as a form of end-organ damage
and an early sign of cardiac dysfunction in patients with
hypertension or multiple metabolic abnormalities (1).
Twelve-lead body surface electrocardiography (ECG) is
a cost-effective tool, and several ECG voltage criteria
for identifying LVH have been widely applied in clinical
practice and for researches. Of these, both sex-independent
Sokolow-Lyon and sex-specific Cornell voltage criteria
are used most commonly (2,3). Moreover, the product
of QRS duration and voltage based on the Sokolow-
Lyon and Cornell criteria for detecting LVH has shown
more accurately than the voltage criteria alone (4,5).
Nevertheless, ECG-derived LVH has been associated with
the occurrence of a wide range of cardiovascular disease
(CVD) such as atrial fibrillation and stroke independent of
echocardiographic LVH in the general population (6,7).
In contrast, professional military members have to take
regular rigorous physical training including endurance and
resistance exercise to maintain their outstanding fitness.
Frequent exercise training and well physical fitness have
been associated with lower risk of incident CVD and
mortality in the general population (8,9). However, there
were conflicting results with regard to the cardiovascular
outcomes in those taking repetitive vigorous exercise (10,11).
To our best knowledge, cardiac remodeling such as left
ventricular muscle hypertrophy and chamber dilatation
are commonly present in athletes (12). Whether these
physiological cardiac adaptations to repetitive strenuous
training on future CVD and mortality events remain
unclear in armed forces. In addition, the prevalence of
ECG-derived LVH in professional military male members
in the East Asian and Jewish populations was estimated
15–20% (13,14), which was much lower than that of 45% in
the elite White male athletes (15).
Although current guideline recommended that
isolated ECG voltage criterion for LVH in athletes was
considered as normal cardiac adaptations to exercise,
evidence for the associations of each ECG criterion
with LVH estimated by imaging studies was lacking
in the military members, especially of the Asian male
population. Therefore the aim of our study was to
compare the Cornell criteria with the Sokolow-Lyon
criteria for the echocardiographic LVH in a large military
male cohort in Eastern Taiwan.
© Cardiovascular Diagnosis and Therapy. All rights reserved.
245
Methods
Study population
The Cardiorespiratory fitness and HospItalization Events
in armed Forces (CHIEF) is a retrospective cohort
consisting of 4,080 professional military members aged
18–50 years completing the annual health examination
and undergoing any one of three exercise tests in eastern
Taiwan during 2014. The study design has been described
in detail previously (14). Of these, there were 620
subjects underwent cardiac examinations of ECG and
echocardiography simultaneously for their promotions
to senior rank and advanced training. Women (n=53)
and those with hypertension (systolic blood pressure
>140 mmHg, or diastolic blood pressure >90 mmHg,
or receiving antihypertensive therapy) or ECG findings
of bundle branch block (n=28) were excluded, leaving a
sample of 539 male members for the final analyses.
Measurements of 12-lead body surface ECG
All standard 12-lead body surface ECGs (Philips
PageWriter Trim III) recorded at 25 mm/sec paper speed
and 1 mV/cm were prospectively performed by a well-
experienced technician (Yun-Shun Yu). ECG variables
including QRS duration, R-wave amplitudes in leads aVL,
V5, and V6, and S-wave amplitudes in leads V1 and V3
were retrospectively measured twice by two well-trained
technicians (Yun-Shun Yu and Felicia Lin), and confirmed
by a cardiologist (Gen-Min Lin) at Hualien-Armed Forces
General Hospital. The Sokolow-Lyon voltage criterion-
based LVH was defined as a composite of amplitudes
(SV1 or V2 + RV5 or V6) ≥35 mm, and the Cornell
voltage criterion-based LVH was defined as RaVL+ SV3
≥28 mm for men (2,3). In addition, the Sokolow-Lyon
product criterion-based LVH was defined as a sum of QRS
duration times the corresponding Sokolow-Lyon voltage
≥3,340 mm × ms, and the Cornell product criterion-based
LVH was defined as QRS duration times the corresponding
Cornell voltage ≥2,440 mm × ms (4,5).
Measurements of echocardiography
All procedures of echocardiography (iE33; Philips Medical
Systems, Andover, MA, USA) were carried out by a well-
experienced technician (Yun-Shun Yu) using a 1–5 MHz
transducer and the reports were reviewed by a cardiologist
(Gen-Min Lin) at Hualien-Armed Forces General Hospital.
cdt.amegroups.com Cardiovasc Diagn Ther 2017;7(3):244-251
246 Su et al. ECG criteria for echocardiographic LVH

Table 1 Baseline characteristics of demographic, anthropometric, by Devereux et al. (17).

and electrocardiographic measurements of the military male LVM = 0.8 × {1.04 × [(left ventricular end diastolic
population diameter (LVIDd) + end diastolic posterior wall thickness
Military male participants (PWTd) + end diastolic interventricular septal thickness
Variables
(n=539) (IVSTd)]3 − LVIDd3} + 0.6
Age (years) 27.9±6.1 LVM was respectively indexed for body surface area
(LVM/BSA, g/m2), according to the Dubois formula, and
Height (cm) 172.0±5.6
for height 2.7 (LVM/height 2.7, g/m 2.7) on the basis of the
Weight (kg) 72.6±11.3 recommendation by de Simone et al. (18). The cut-off value
Waist (cm) 83.1±9.2 for echocardiographic LVH was set as LVM/BSA ≥116
Current smoker, n (%) 111 (20.6)
g/m2 and LVM/height 2.7 ≥49 g/m2.7 in the military male
2
population (19).
Body mass index (kg/m ) 24.5±3.6

Underweight (<18.5) (%) 17 (3.2)

Statistical analysis
Normal (18.5–24.9) (%) 303 (56.2)
Baseline characteristics of the CHIEF military male
Overweight (25–29.9) (%) 181 (33.6)
cohort were reported as mean ± standard deviation
Obesity (≥30) (%) 38 (7.1)
or percent for continuous and categorical variables
2
Body surface area (m ) 1.81±0.16 respectively. Pearson’s correlation coefficient (r) was used
Systolic blood pressure (mmHg) 120.1±13.1 to determine the degree of correlation between each
ECG criterion and the two LVM indexes, and compared
Diastolic blood pressure (mmHg) 71.8±10.3
by the Fisher’s z test. Receiver-operating characteristics
Heart rate (beats/min) 67.6±12.0 (ROC) curves were used to compare the performance
Sokolow-Lyon V (mm) 33.4±8.1 of each ECG criterion for the echocardiographic LVH
Cornell V (mm) 9.8±5.5 over a range of specificities. Pairwise comparisons of
the four ECG criteria for LVH were performed using
QRS duration (ms) 96.6±12.0
differences between the areas under the curves (AUC).
Sokolow-Lyon P (mm × ms) 3,308.7±907.7 The sensitivity and specificity of each ECG criterion-
Cornell P (mm × ms) 982.9±573.3 derived cut-off value for echocardiographic LVH were
Continuous variables are expressed as mean ± standard compared. In addition, we also calculated the sensitivities
deviation and categorical variables as number (percentage). V, and corresponding cut-off values for each criterion at
the voltage criterion; P, the product criterion. fixed specificity levels of 90%, 95%, and 100% (20). A
two-tailed value of P<0.05 was considered significant.
All analyses were performed using SAS version 9.4 (SAS
All study subjects were prepared in supine and left lateral Institute, Cary, NC, USA).
positions and examined using parasternal long-axis and
short-axis views and in the apical four and two-chamber Ethic statement
views. On the basis of the recommendations of the American
This study was approved by the Institutional Review Board
Society of Echocardiography (16), quantification of left
of the Mennonite Christian Hospital (No. 16-05-008) in
ventricular chamber dimension (diastolic diameter) and wall
Hualien, Taiwan. Informed consent was not required by the
thickness (interventricular septal and posterior wall) were
Board because of a retrospective study.
measured approximately at the mitral valve tips and at the
onset of the QRS complex of end diastole in parasternal
long axis view. M-mode and two-dimensional measurements Results
of left ventricular mass (LVM) used the leading edge-to- The baseline demographic, anthropometric, ECG, and
leading-edge method. LVM was calculated based on the echocardiographic characteristics of the military male cohort
corrected American Society of Echocardiography formula were shown in Table 1 and Table 2 respectively. Ages in the

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Cardiovascular Diagnosis and Therapy, Vol 7, No 3 June 2017 247

Table 2 Baseline echocardiographic parameters of the military Table 3 Pearson correlation coefficient (r) of electrocardiographic
population criteria with the left ventricular mass indexes in the military male
population
Military male
Echocardiographic variables
participants (n=539) Electrocardiographic LVM/BSA LVM/height2.7

Aortic valve opening (mm) 19.2±1.9 criteria r P value r P value

†
Aortic root dimension (mm) 27.3±14.2 Sokolow-Lyon V (mm) 0.16 0.0003 0.049*, 0.2600

Interventricular septum (mm) 9.6±1.5 Cornell V (mm) 0.25 <0.0001 0.240 <0.0001
†
LV posterior wall (mm) 9.3±1.1 Sokolow-Lyon P 0.20 <0.0001 0.095 0.0290
(mm × ms)
LV end-diastolic dimension (mm) 48.7±3.7
Cornell P (mm × ms) 0.28 <0.0001 0.260 <0.0001
LV end-systolic dimension (mm) 30.3±4.0
LVM/BSA, left ventricular mass indexed by body surface area;
LV ejection fraction (%) 61.5±5.5
LVM/height2.7, left ventricular mass indexed by height2.7; V, the
LA dimension (mm) 32.8±13.7 voltage criterion; P, the product criterion; *, P<0.01 vs. Cornell V;
†
, P<0.01 vs. Cornell P.
RVOT-prox dimension (mm) 28.3±13.9

RV systolic pressure (mmHg) 26.7±5.8

Mitral inflow E wave (cm/s) 82.9±15.2 between the ECG voltage and the product criterion with
Mitral inflow A wave (cm/s) 49.2±10.9 the LVM indexes.
2
LVM/BSA (g/m ) 90.3±18.1

LVM/height 2.7
(g/m ) 2.7
37.9±8.7
Prevalence of LVH
By LVM/BSA, n (%) 36 (6.7)
2.7
By LVM/height , n (%) 45 (8.4)
Continuous variables are expressed as mean ± standard
deviation and categorical variables as number (percentage). LV,
left ventricle; LA, left atrium; RVOT-prox, proximal right ventricular
out tract; RV, right ventricle; LVH, left ventricular hypertrophy;
LVM/BSA, left ventricular mass indexed by body surface area;
LVM/height2.7, left ventricular mass index by height2.7.
study subjects were between 18 and 50 years and more than
95% of them were less than 40 years. The prevalence of
echocardiographic LVH was 6.7% as LVM/BSA ≥116 g/m2
and 8.4% as LVM/height2.7 ≥49 g/m2.7 respectively.
Correlation of each ECG criterion with the LVM indexes
Table 3 shows that all four ECG criteria were correlated
with the LVM/BSA index (r=0.217−0.507). However, the
Sokolow-Lyon voltage criterion was not correlated with
the LVM/height2.7 index. The correlation coefficients of
the Cornell criteria were higher than that of Sokolow-Lyon
criteria, but this result was significant only for the LVM/
height2.7 index. In addition, there were similar correlations
Performance of the four ECG criteria for the
echocardiographic LVH using ROC curve and traditional
cut-off value
Figure 1A shows similar AUC (range, 0.61–0.66) among
the four ECG criteria for the LVM/BSA ≥116 g/m 2
except that the AUC of the Sokolow product criterion was
modestly higher than that of the Sokolow voltage criterion
(0.66 vs. 0.61). In contrast, Figure 1B shows that the Cornell
voltage and product criteria had higher AUC (0.66 and 0.68
respectively) than those of Sokolow-Lyon criteria (0.54 and
0.53 respectively) for the LVM/height2.7 ≥49 g/m2.7. The
differences between the Cornell and the Sokolow-Lyon
criteria were almost significant except the difference in
the voltage criteria. Table 4 shows that the sensitivities for
the traditional cut-off values were generally low, especially
using the Sokolow-Lyon voltage and product criteria for the
LVM/BSA ≥116 g/m2 and LVM/height2.7 ≥49 g/m2.7 indexes
of LVH (6.7–8.3% and 4.4–8.3% respectively). The test-
negative likelihood ratio was estimated from 0.76 to 0.98
due to the low sensitivities of the four ECG criteria for the
echocardiographic LVH.
Performance of the four ECG criteria using revised cut-off
values
Since the specificities were all around 95% using traditional

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248 Su et al. ECG criteria for echocardiographic LVH

A LVM/BSA B LVM/height2.7
100 100

80 80

60 60
Sensitivity

Sensitivity
40 40

AUC (95% CI)_ LVM/height2.7 P

AUC (95% CI) by LVM/BSA P
Sok V 0.54 (0.45–0.62) 0.420
20 Sok V 0.61 (0.52–0.70) 0.029
* 20 Sok P 0.53 (0.44–0.61) 0.580
Sok P 0.66 (0.57–0.75) 0.002 * † *
Cor V 0.66 (0.57–0.75) 0.000
Cor V 0.63 (0.53–0.74) 0.007 *
Cor P 0.68 (0.60–0.77) 0.000
Cor P 0.65 (0.55–0.75) 0.002
0 0
0 20 40 60 80 100 0 20 40 60 80 100
100-specificity 100-specificity
Echo_Sok P Echo_Cor P Echo_Sok V Echo_Cor V Echo_Sok P Echo_Cor P Echo_Sok V Echo_Cor V

Figure 1 The receiver-operating characteristics (ROC) curve with electrocardiographic criteria for identifying left ventricular hypertrophy
(LVH) in the military male population in Taiwan. (A) The ROC curve with four electrocardiographic criteria [the Cornell voltage (Cor V)
and production (Cor P), and the Sokolow-Lyon voltage (Sok V) and product (Sok P) criteria] for identifying LVH using left ventricular mass
(LVM)/body surface area ≥116 g/m2; (B) the ROC curve for defining LVH using LVM/height2.7 49 g/m2.7. *, P<0.05; †, P<0.01.

Table 4 Sensitivities and specificities at conventional cut-off values (specificity=95%) for diagnosing echocardiographic LVH in the military male
population

Electrocardiographic LVM/BSA LVM/height2.7

criteria Sensitivity (%) Specificity (%) LR+ LR− Sensitivity (%) Specificity (%) LR+ LR−

Sokolow-Lyon V 8.3 95.0 1.7 0.97 6.7 95.3 1.4 0.98

Cornell V 22.2 95.2 4.6 0.82 17.8 95.1 3.6 0.86

Sokolow-Lyon P 8.3 95.2 1.7 0.96 4.4 95.1 0.9 1.00

Cornell P 27.8 95.2 5.8 0.76 22.2 95.1 4.5 0.82

2.7 2.7
LVM/BSA, left ventricular mass indexed by body surface area; LVM/height , left ventricular mass indexed by height ; LR+, likelihood ratio
of a positive test; LR−, likelihood ratio of negative test; V, the voltage criterion; P, the product criterion.

cut-off values, the sensitivity of cut-off value for each ECG
criterion at a fixed specificity level of 95% was unchanged
(Table 5). Notably, the sensitivities remained the lowest,
using the Sokolow-Lyon criteria for the LVM/height2.7
2.7
≥49 g/m (4.4–11.1%) at a fixed specificity level of 90%.
Discussion
Our principal finding was that both of the Cornell
voltage and product ECG criteria performed superior
to the Sokolow-Lyon criteria in the correlation with the
echocardiographic LVM/height2.7 defined LVH and the
AUC of the ROC in a young military male population
in Taiwan. Another important finding was that there
was no difference between the Cornell voltage and the
product criteria in the performance for detecting the
echocardiographic LVH. In addition, the Cornell voltage
and product ECG criteria showed better sensitivity than the
Sokolow-Lyon criteria under a fixed specificity of 95%.
Most previous studies investigating the performance of
different ECG criteria for LVH evaluated by echocardiography
or magnetic resonance imaging were conducted in
hypertensive patients of the Western countries (21,22).
Some studies have shown that there was ethnical difference
between hypertensive Whites and African Americans in
the ECG diagnostic performance (23,24). In summary,

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Cardiovascular Diagnosis and Therapy, Vol 7, No 3 June 2017 249

Table 5 The sensitivities and revised cut-off values at specificity levels of 90%, 95%, and 100% for diagnosing echocardiographic LVH

LVM/BSA LVM/height2.7
Electrocardiographic
criteria Sensitivity (%) Cut-off values Sensitivity (%) Cut-off values
(mm or mm × ms) (mm or mm × ms)

Specificity (%) 90.0 95.0 100.0 90.0 95.0 100.0 90.0 95.0 100.0 90.0 95.0 100.0

Sokolow-Lyon V 19.4 8.3 2.8 43.6 47.6 56.0 11.1 6.7 0 10 20.7 22.8

Cornell V 36.1 22.2 5.6 16.1 18.3 26.0 33.3 17.8 4.4 16.1 18.3 26.0

Sokolow-Lyon P 19.4 8.3 0 4,541.6 2,876.1 7,416.5 4.4 4.4 0 4,591.9 4,879.4 7,416.5

Cornell P 33.3 27.8 2.8 1,688.2 1,844.3 3,039.2 26.7 22.2 2.2 1,688.2 1,844.3 3,029.2
2.7
LVH, left ventricular hypertrophy; LVM/BSA, left ventricular mass indexed by body surface area; LVM/height ; left ventricular mass
indexed by height2.7; V, the voltage criterion; P, the product criterion.

the Sokolow-Lyon voltage criterion had better sensitivity
in African American patients, but in contrast the Cornell
voltage criterion was superior in White patients. However,
there were few studies for the association of ECG criteria
with LVH in the Asian populations. In Chinese patients with
hypertension (25), Xie et al. uncovered that the Cornell
voltage and product criteria had better sensitivity to detect
echocardiographic LVH than other criteria in men and
women. In Korean patients, Park et al. demonstrated that
the Cornell product criterion was superior in woman, but
the Sokolow-Lyon product criterion had better sensitivity
in men (20).
As compared with the correlations of the ECG criteria
with the LVM index in middle-aged male patients with
hypertension, we found that the correlation coefficients
were much less in the young military male cohort free of
hypertension in Taiwan (30–50% vs. 15–30%) (20,25). In
line with previous reports, use of the ECG criteria in the
diagnosis of LVH is limited in the male military population
as well because of the low sensitivity of the method (26). As
is known, the prevalence of ECG-defined LVH was high in
professional military members undergoing regular rigorous
exercise training, however the prevalence of echocardiographic
LVH was relatively low which was less than 10% in the present
study and in the Israeli Air Force study (13). As a result, the
correlations of the ECG criteria with the LVM index may be
decreased in the military male cohort free of hypertension.
In addition, the sensitivity of a combined Sokolow-Lyon and
Cornell voltage criterion for LVH in the Israeli Air Force
study was higher than that in the present study (55% vs.
30%). This might be explained by a more strict definition of
echocardiographic LVH in the Israeli study, which was set as
the LVM/BSA index ≥132 g/m2.
The Sokolow-Lyon voltage and product criteria had
poor correlations with the LVM/height2.7 and the AUC of
the ROC for the index in the present study. This finding
was unexpected and not consistent with the Cornell
ECG criteria. The reason could be explained in part by
that unlike the Cornell criteria using frontal lead RaVL
amplitude, the Sokolow-Lyon criteria used precordial leads
amplitudes only and might be affected much if the LVM
was indexed for height raising to an exponential power of
2.7. Therefore the application of the Sokolow-Lyon criteria
for echocardiographic LVH should be cautious in the young
fit male subjects for the LVM/height2.7 index.
There were several limitations in our study. First, the
study population included only male subjects, making it
difficult to apply the results to the female subjects. Second,
the military members were considered to be a healthy
cohort and the results could not be applied to the general
populations who have multiple comorbidities. Third,
we compared the Sokolow-Lyon with the Cornell-based
criteria for echocardiographic LVH and the accuracy of
other ECG criteria needs further investigation. Fourth, a
small number of patients with hypertrophic cardiomyopathy
might be included in the LVH group. Finally the present
male cohort accounted for only 15% of the overall CHIEF
male cohort, which might result in a selection bias despite
that the baseline characteristics were similar to that of the
overall CHIEF male cohort. In conclusion, the Cornell
voltage and product criteria for echocardiographic LVH had
better performance than the Sokolow-Lyon ECG criteria
in a young military male cohort in Taiwan. In addition,
the Sokolow-Lyon criteria should be cautiously used to

© Cardiovascular Diagnosis and Therapy. All rights reserved. cdt.amegroups.com Cardiovasc Diagn Ther 2017;7(3):244-251
250
correlate the index of LVM/height2.7 in this population.
Acknowledgements
Funding: The study was supported by the Research Grants
from the Hualien-Armed Forces General Hospital (805-
C105-10) and the Ministry of National Defense-Medical
Affairs Bureau (MAB-106-124).
Footnote
Conflicts of Interest: The authors have no conflicts of interest
to declare.
Ethical Statement: This study was approved by the
Institutional Review Board of the Mennonite Christian
Hospital (No. 16-05-008) in Hualien, Taiwan. Informed
consent was not required by the Board because of a
retrospective study.
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